Bilateral uveitis following nivolumab and ipilimumab treatment for mesothelioma

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AbstractPurpose: Case report of a patient presenting with sudden onset of painful decreased vision in both eyes, diagnosed with Intermediate uveitis and keratitis. We will review the diagnostic pathway and the management of this case, as well as the correlation with the systemic treatment of that time.Results: A 63‐year‐old male presented in the Emergency department with bilateral red painful eyes and blurred vision. The patient had a past ophthalmic history of keratouveitis in RE and medical history of mesothelioma for which he had recently started treatment with Nivolumab and Ipilimumab. The visual acuity on presentation was 6/9 in the RE and 6/6 in the LE. Upon examination BE were hyperaemic, there was a past corneal scar in the RE and bilateral KPs. RE had +1 AC inflammation and LE traces of AC inflammation. No signs of posterior segment inflammation were seen in both eyes. The patient was treated initially with oral Aciclovir 400 mg BD and Pred Forte 1% in BE QDS. One week after initiation of treatment symptoms improved and a tapering regime of the local steroid treatment was given. Four weeks later the visual acuity in the RE was 6/12 and 6/9 in the LE. Upon examination there was +1 AC activity in BE and +1 vitreous activity. OCT demonstrated bilateral macular oedema. An FFA revealed bilateral optic disc hyperfluorescence. Upon further discussion of the patient's medical history it was revealed that both episodes of intraocular activity coincided with his infusions of Nivolumab and Ipilimumab. The patient was advised to discontinue the oral Aciclovir treatment and was initiated on intensive regime of local steroids which was tapered on improvement of the vision and the inflammation. Our ocular findings were communicated the patient's oncology team that decided to discontinue the above treatment.Conclusions: Nivolumab is an anti‐programmed cell death protein‐monoclonal. It is used for cancer treatment but case reports have emerged of uveitis and ocular surface disease. Ipilimumab is a humanized CLTA‐4 antibody and it can be associated with immune related adverse events such as uveitis. Our patient was switched to a different treatment protocol without further ocular inflammation and excellent visual outcome. Clinicians should raise their index of suspicion in side effects around the timing of treatment.